Richmond Agitation Sedation Score

Question 1

RASS:

Answer 1

Richmond Agitated Sedation Score (+4 -> -5)

Question 2

Violent, immediate danger to staff:

Answer 2

Combative (+4)

Question 3

Agressive, pulls to remove tubes or catheters:

Answer 3

Very Agitated (+3)

Question 4

Frequent non-purposeful movement, fights ventilator:

Answer 4

Agitated (+2)

Question 5

Anxious, apprehensive, movements not aggressive:

Answer 5

Restless (+1)

Question 6

Spontaneously pays attention to the caregiver:

Answer 6

Alert and Calm (0)

Question 7

Not fully alert, but has sustained awakening to voice:

Answer 7

Drowsy (-1)

Question 8

Sustained awakening:

Answer 8

Eye opening and contact +10s

Question 9

Briefly awakens to voice, with eye opening and contact:

Answer 9

Light Sedation (-2)

Question 10

Movement or eye opening to voice, without eye contact:

Answer 10

Moderate Sedation (-3)

Question 11

No response to voice, but movement or eye opening to physical stimulation:

Answer 11

Deep Sedation (-4)

Question 12

No response to voice or physical stimulation:

Answer 12

Unarousable (-5)